GLP-1 patients may experience a range of side effects, from negligible concerns to more significant gastrointestinal (GI) issues such as diarrhea, abdominal bloat or cramping, and constipation. Among the side effects, your patients may share they’re experiencing something unpleasant and unpredictable: sulfur burps.

“Sulfur burps are just burps that may have a taste or smell of sulfur or rotten eggs,” said Rekha B. Kumar, MD, an endocrinologist at NewYork-Presbyterian and Weill Cornell Medicine, both in New York City. “Typically, they occur with the breakdown of sulfur-rich foods like proteins and cruciferous vegetables.”

The Connection Between GLP-1s and Sulfur Burbs

GLP-1’s can increase the likelihood of having sulfur burps because it takes the stomach longer to empty on a GLP-1 medication so proteins and other rich sulfur foods may sit in the stomach longer leading to burping and gaseous material from the contents of the food in the stomach, Kumar said. Patients who already have delayed stomach emptying for other reasons or who already have acid reflux might be more prone to this, she said.

Patient Management of Symptoms

Beyond suggestions such as over-the-counter (OTC) remedies or diet modifications, primary care providers (PCPs) can ask patients to consume their highest protein meals earlier in the day so there is time for digestion before they lay down, she said. Also, suggesting eating more slowly can help signify fullness and they are less likely to overeat.

About diet tweaks, consider these directives.

“Reduce intake of sulfur-rich foods, eggs, broccoli, garlic, and avoid carbonated drinks and alcohol,” said Kumar. “Eat smaller, frequent meals, stay hydrated, and take OTC remedies like Pepto-Bismol, simethicone, or antacids.”

Take Sulfur Burp Concerns Seriously

Don’t ignore a discussion of symptoms and frequency of sulfur burps. “It is important to ask so we don’t miss other digestive disease like acid reflux or hernias that may also cause sulfur burps,” said Kumar.

Further assessment into the scientific factors contributing to sulfur burps is warranted. Yuval Pinto, MD, assistant professor of medicine and part of the Healthful Eating, Activity & Weight Program at Johns Hopkins School of Medicine in Baltimore, also noted GLP-1 use is associated with sulfur burps as they mimic hormones that slow gastric emptying.

“This delay prolongs food contact with bacteria, enhancing fermentation of sulfur-containing substrates and hydrogen sulfide production,” he said.

Regarding patient management, he said real-world and trial data confirm increased eructation and related symptoms, often early in treatment or with abrupt dose escalation.

“Higher doses and more potent incretin therapies (eg, high-dose tirzepatide, semaglutide) are associated with greater overall GI adverse reactions, suggesting that more aggressive hormonal modulation increases the likelihood of fermentative symptoms, including malodorous gas,” he said.

High-Risk Patients and Sulfur Burp Concerns and Management

Consider a more tailored approach to these patient populations, Pinto said.

• Patients with baseline gastric motility disorders. These conditions include but are not limited to diabetic gastroparesis, chronic constipation, prior functional dyspepsia, and pose a higher risk as gastric emptying is delayed, said Pinto. “That could worsen when GLP-1 RAs [receptor agonists] are added. The delayed emptying facilitates gas accumulation and fermentation.”
• Patients with type 2 diabetes. Consider patient-centric care especially those with autonomic neuropathy or motility impairment.
• Patients who experience rapid GLP-1 dose titration. Monitoring symptoms can help.
• Patients with preexisting GI conditions. These can include small intestinal bacterial overgrowth (SIBO), irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), prior SIBO, or other gastroparesis risk factors, said Pinto.
• Patients who follow high-sulfur diets. These dietary triggers may include eggs, red meat, cruciferous vegetables, he said.

How Can PCPs Help?

As a partner in your patient’s healthcare management, Pinto recommended these approaches:

• Dietary modifications: Recommend small, frequent, low-sulfur, low-fat meals. Advise patients to eat five to six small meals, chewing thoroughly, and limiting high-sulfur foods and high-fat items.
• Increase hydration and post-meal physical activity. Recommend 2-3 L of water intake daily and 10-20 minutes moderate walks after meals.
• Adjustment of GLP-1 RA: “GI tolerability of GLP-1 RA is dose- and exposure-specific, thus, a careful control on the gastric ‘brake’ is necessary,” Pinto said.
• Screen and treat for SIBO. These cases of persistent sulfur burps plus bloating, diarrhea, or abdominal discomfort, should be further investigated, he said. The PCP should consider proper breath testing and manage positive SIBO with appropriate antibiotics and, when needed, motility support, Pinto also said.

Pinto reported no disclosures. Kumar reported being a consultant for Found Health, Inc., and an advisory/scientific board member for Skye Bioscience Inc.